The form records the voter's name and dates of birth, residence, voter registration, and first poll tax payment. Annual payments, from 1950 to 1997, were to be recorded in spaces at the bottom of the form.

The form records the voter's name and dates of birth, residence, voter registration, and first poll tax payment. Annual payments, from 1950 to 1997, were to be recorded in spaces at the bottom of the form.